Deep learning algorithm for predicting subacromial motion trajectory: Dynamic shoulder ultrasound analysis

Subacromial motion metrics can be extracted from dynamic shoulder ultrasonography, which is useful for identifying abnormal motion patterns in painful shoulders. However, frame-by-frame manual labeling of anatomical landmarks in ultrasound images is time consuming. The present study aims to investigate the feasibility of a deep learning algorithm for extracting subacromial motion metrics from dynamic ultrasonography. Dynamic ultrasound imaging was retrieved by asking 17 participants to perform cyclic shoulder abduction and adduction along the scapular plane, whereby the trajectory of the humeral greater tubercle (in relation to the lateral acromion) was depicted by the deep learning algorithm. Extraction of the subacromial motion metrics was conducted using a convolutional neural network (CNN) or a self-transfer learning-based (STL)-CNN with or without an autoencoder (AE). The mean absolute error (MAE) compared with the manually-labeled data (ground truth) served as the main outcome variable. Using eight-fold cross-validation, the average MAE was proven to be significantly higher in the group using CNN than in those using STL-CNN or STL-CNN+AE for the relative difference between the greater tubercle and lateral acromion on the horizontal axis. The MAE for the localization of the two aforementioned landmarks on the vertical axis also seemed to be enlarged in those using CNN compared with those using STL-CNN. In the testing dataset, the errors in relation to the ground truth for the minimal vertical acromiohumeral distance were 0.081-0.333 cm using CNN, compared with 0.002-0.007 cm using STL-CNN. We successfully demonstrated the feasibility of a deep learning algorithm for automatic detection of the greater tubercle and lateral acromion during dynamic shoulder ultrasonography. Our framework also demonstrated the capability of capturing the minimal vertical acromiohumeral distance, which is the most important indicator of subacromial motion metrics in daily clinical practice.

Subacromial impingement syndrome: association of multiple magnetic resonance imaging parameters with shoulder function and pain

INTRODUCTION

Shoulder pain is one of the most common complaints in orthopaedics. This study focusses on the relationship between shoulder function in subacromial impingement syndrome and imaging criteria in magnetic resonance imaging (MRI).

MATERIALS AND METHODS

This prospective clinical trial included 69 patients treated for subacromial impingement syndrome. Shoulder function (Constant Score, range of abduction, abduction force) and pain were correlated with the following MRI parameters: tendinosis of the rotator cuff, "halo-sign" around the biceps tendon, subacromial distance, critical shoulder angle, size of subacromial osteophytic spurs and maximum width of subacromial and subdeltoid bursa. Statistical analyses included Pearson's and Spearman's coefficients of correlation, multiple regression analysis and Student's t-test.

RESULTS

The Constant Score was correlated positively with the critical shoulder angle (r = 0.313; p = 0.009) and inversely with a "halo-sign" around the biceps tendon (rho =  -0.384; p = 0.001). There was no significant correlation between spur size and shoulder function, but the size of the subacromial and subdeltoid bursae was positively correlated with the subacromial spur's size (subacromial bursa: coronal plane: r = 0.327; p = 0.006; sagittal view: r = 0.305; p = 0.011; subdeltoid bursa coronal view: r = 0.333 p = 0.005). The width of the subdeltoid bursa in coronal plane was positively correlated with shoulder pain (r = 0.248; p = 0.004) and negatively with the range of abduction (r =  -0.270; p = 0.025), as well as the mean (r =  -0.332; p = 0.005) and maximum (r =  -0.334; p = 0.005) abduction force.

CONCLUSIONS

Shoulder function and pain in subacromial impingement are best predicted by the width of the subdeltoid bursa measured in the coronal MRI plane as an indicator of bursitis as well as the presence of a "halo-sign" around the biceps tendon indicating glenohumeral joint effusion. Presence of a subacromial spur could lead to subacromial and subdeltoid bursitis, which impairs shoulder function. Shoulder function seems not to be compromised by the presence of a subacromial spur in absence of bursitis. This study was registered at the German Clinical Trials Register on 08 February 2013 (ID: DRKS00011548).

Diagnostic labels and advice for rotator cuff disease influence perceived need for shoulder surgery: an online randomised experiment

QUESTION

What are the effects of diagnostic labels and advice, and interactions between labels and advice, on perceived need for shoulder surgery for rotator cuff disease?

DESIGN

2×2 factorial online randomised experiment.

PARTICIPANTS

People with shoulder pain.

INTERVENTION

Participants read a scenario describing a patient with rotator cuff disease and were randomised to bursitis label plus guideline-based advice, bursitis label plus treatment recommendation, rotator cuff tear label plus guideline-based advice, and rotator cuff tear label plus treatment recommendation. Guideline-based advice included encouragement to stay active and positive prognostic information. Treatment recommendation stressed that treatment is needed for recovery.

OUTCOME MEASURES

Perceived need for surgery (primary outcome), imaging, an injection, a second opinion and to see a specialist; and perceived seriousness of the condition, recovery expectations, impact on work performance and need to avoid work.

RESULTS

A total of 2,024 responses (99.8% of 2,028 randomised) were analysed. Labelling as bursitis (versus rotator cuff tear) decreased perceived need for surgery (mean effect -0.5 on a 0-to-10 scale, 98.3% CI -0.7 to -0.2), imaging and to see a specialist, and perceived seriousness of the condition and need to avoid work. Guideline-based advice (versus treatment recommendation) decreased perceived need for surgery (mean effect -1.0, 98.3% CI -1.3 to -0.7), imaging, an injection, a second opinion and to see a specialist, and perceived seriousness of the condition and recovery expectations. There was little to no evidence of an advice label interaction for any outcome.

CONCLUSION

Labels and advice influenced perceived need for surgery and other secondary outcomes in people with rotator cuff disease, with larger effects for advice. There was evidence of little or no interaction between labels and advice for any outcome, but the additive effect of labels and advice appeared large for some outcomes (eg, perceived need for imaging and perceived seriousness of the condition).

TRIAL REGISTRATION

ACTRN12621001370897.

Pain does not explain reduced teres major co-contraction during abduction in patients with Subacromial Pain Syndrome

BACKGROUND

Patients with Subacromial Pain Syndrome show reduced co-contraction of the teres major during abduction. Consequent insufficient humeral depressor function may contribute to painful irritation of subacromial tissues and offers a potential target for therapy. A crucial gap in knowledge is whether the degree of teres major co-contraction in these patients is influenced by pain itself. To gain insight into this matter, we assessed whether relief of subacromial pain with local analgesics leads to increased adductor co-contraction in 34 patients with subacromial pain.

METHODS

In a single-arm interventional study with 34 patients, electromyographic activity of the latissimus dorsi, pectoralis major, teres major and deltoid was assessed during isometric force tasks in 24 directions before and after subacromial Lidocaine injection. Co-contraction was quantified using the activation ratio; range [-1 (sole antagonistic activation, i.e. co-contraction) to 1 (sole agonistic activation)].

FINDINGS

There were no changes in activation ratio of the teres major after the intervention (Z-score: -0.6, p = 0.569). The activation ratio of the latissimus dorsi increased to 0.38 (quartiles: 0.13-0.76), indicating decreased co-contraction (Z-score: -2.0, p = 0.045).

INTERPRETATION

Subacromial analgesics led to a decrease in co-contraction of the latissimus dorsi, whereas no change in the degree of teres major co-contraction was observed. This study shows that decreased teres major co-contraction in patients with subacromial pain, likely is not the consequence of pain itself, opening a window for physical therapy with training of teres major co-contraction to reduce subacromial irritation and pain.

LEVEL OF EVIDENCE

Level II treatment study.

Evidence for increased neuromuscular drive following spinal manipulation in individuals with subacromial pain syndrome

BACKGROUND

Thoracic spinal manipulation can improve pain and function in individuals with shoulder pain; however, the mechanisms underlying these benefits remain unclear. Here, we evaluated the effects of thoracic spinal manipulation on muscle activity, as alteration in muscle activity is a key impairment for those with shoulder pain. We also evaluated the relationship between changes in muscle activity and clinical outcomes, to characterize the meaningful context of a change in neuromuscular drive.

METHODS

Participants with shoulder pain related to subacromial pain syndrome (n = 28) received thoracic manipulation of low amplitude high velocity thrusts to the lower, middle and upper thoracic spine. Electromyographic muscle activity (trapezius-upper, middle, lower; serratus anterior; deltoid; infraspinatus) and shoulder pain (11-point scale) was collected pre and post-manipulation during arm elevation, and normalized to a reference contraction. Clinical benefits were assessed using the Pennsylvania Shoulder Score (Penn) at baseline and 2-3 days post-intervention.

FINDINGS

A significant increase in muscle activity was observed during arm ascent (p = 0.002). Using backward stepwise regression analysis, a specific increase in the serratus anterior muscle activity during arm elevation explained improved Penn scores following post-manipulation (p < 0.05).

INTERPRETATION

Thoracic spinal manipulation immediately increases neuromuscular drive. In addition, increased serratus anterior muscle activity, a key muscle for scapular motion, is associated with short-term improvements in shoulder clinical outcomes.

Correlation between full-thickness degenerative supraspinatus tear and radiographic parameters including the acromiohumeral centre edge angle and the greater tuberosity angle

BACKGROUND

Many radiographic parameters associated with the extrinsic cause of supraspinatus tears have been proposed. The aim of this study was to assess the relationship between a full-thickness degenerative supraspinatus tear (FTDST) and the patient's radiographic parameters, including the acromiohumeral centre edge angle (ACEA) and the greater tuberosity angle (GTA).

METHODS

A retrospective study was conducted. We included 116 patients who underwent shoulder arthroscopic surgery at our institute. The case group included FTDST patients, whereas the control group also included patients without evidence of supraspinatus tears. In each patient, the ACEA and GTA values were measured and analyzed by two independent observers. Intra- and interobserver reliabilities were assessed. Multivariate regression analysis was performed.

RESULTS

The ACEA values were significantly increased in the FTDST group with a mean of 26.44° ± 9.83° compared with 16.81° ± 7.72° in the control group (P < 0.001). Multivariate regression analysis also showed that higher ACEA values were associated with an FTDST (odds ratio 1.16 per degree, P = 0.01). For GTA values, a statistically significant difference was found with a mean of 70.92° ± 6.64 compared with 67.84° ± 5.56 in the control group (P = 0.02). However, stepwise regression analysis did not indicate that GTA was a predictor of FTDST.

CONCLUSIONS

Our study demonstrated that the presence of increased ACEA values is an independent significant risk factor for the presence of FTDSTs. Consequently, GTA values may be less helpful in assessing the risk of FTDST, especially in this specific population.

Reduced psychosocial functioning in subacromial pain syndrome is associated with persistence of complaints after 4 years

BACKGROUND

Patients with subacromial pain syndrome (SAPS) frequently present with coexisting psychosocial problems; however, whether this also associates with long-term outcome is currently unknown. We assessed whether psychosocial functioning in patients with SAPS is associated with persistence of complaints after 4 years of routine care.

METHODS

In a longitudinal study, 34 patients with SAPS were selected after clinical and radiologic evaluation and assessed at baseline and after 4 years. For the assessment of psychosocial functioning, the RAND-36 questionnaire domains of social functioning, role limitations due to emotional problems, mental health, vitality, and general health were evaluated. Complaint persistence at follow-up was assessed by (1) an anchor question (reduced, persistent, or increased symptoms), (2) change in pain (change in visual analog scale score), and (3) change in quality of life (change in Western Ontario Rotator Cuff index score).

RESULTS

Lower baseline mental health (odds ratio [OR], 0.92; 95% confidence interval [CI], 0.85-0.98; P = .013), vitality (OR, 0.90; 95% CI, 0.83-0.98; P = .011), and general health (OR, 0.93; 95% CI, 0.88-0.98; P = .009) were associated with persistent complaints as reported by the anchor question, change in visual analog scale score, and change in Western Ontario Rotator Cuff index score.

CONCLUSIONS

Evaluating psychosocial functioning parallel to physical complaints is currently not standard procedure in the treatment of SAPS. In this study, we showed that factors related to psychosocial functioning are associated with long-term persistence of complaints in SAPS. Future studies may investigate whether a multimodal treatment with assessment of psychosocial functioning may facilitate pain relief and recovery in SAPS.

A computer tablet software can quantify the deviation of scapula medial border from the thoracic wall during clinical assessment of scapula dyskinesis

PURPOSE

Aim of this study is to establish an objective and easily applicable method that will allow clinicians to quantitatively assess scapular dyskinesis during clinical examination using a computer tablet software. Hypothesis is that dyskinetic scapulae present greater motion-deviation from the thoracic wall-compared to the non-dyskinetic ones and that the software will be able to record those differences.

METHODS

Twenty-five patients and 19 healthy individuals were clinically evaluated for the presence of dyskinesis or not. According to the clinical diagnosis, the observations were divided into three groups; A. Dyskinetic scapulae with symptoms (n = 25), B. Contralateral non-dyskinetic scapulae without symptoms (n = 25), C. Healthy control scapulae (n = 38). Then, all individuals were tested using a tablet with the PIVOT™ image-based analysis software (PIVOT, Impellia, Pittsburgh, PA, USA). The motion produced by the scapula medial border and inferior angle deviation from the thoracic wall was recorded.

RESULTS

The deviation of the medial border and inferior angle of the scapula from the thoracic wall was 24.6 ± 7.3 mm in Group A, 14.7 ± 4.9 mm in Group B, and 12.4 ± 5.2 mm in Group C. The motion recorded in the dyskinetic scapulae group was significantly greater than both the contralateral non-dyskinetic scapulae group (p < 0.01) and the healthy control scapulae group (p < 0.01).

CONCLUSION

The PIVOT™ software was efficient to detect significant differences in the motion between dyskinetic and non-dyskinetic scapulae. This system can support the clinical diagnosis of dyskinesis with a numeric value, which not only contributes to scapula dyskinesis grading but also to the evaluation of the progress and efficacy of the applied treatment, thus providing a feedback to the clinician and the patient.

LEVEL OF EVIDENCE

IV, laboratory study.

CORRELATION BETWEEN THE KERLAN-JOBE ORTHOPEDIC CLINIC SCREEN AND SUBACROMIAL IMPINGEMENT TEST-ITEM CLUSTER IN COLLEGIATE BASEBALL PITCHERS: A PILOT STUDY

Background

Shoulder injuries in baseball related to throwing account for 60% of all baseball injuries and 75% of those throwing injuries occur in pitchers. Impingement is the beginning of a continuum of rotator cuff pathology that can result in pain and disability in pitchers. Identification of self-reported measures and clinical tests that can indicate early pathology of shoulder impingement is needed for overhead athletes. Early identification of shoulder impingement is important to the long-term health and function of these athletes.

Hypothesis/Purpose

The purpose of this study was to determine if a correlation exists between self-reported pain and disability using the Kerlan-Jobe Orthopedic Clinic (KJOC) score and the Park Test-Item Cluster (TIC) for subacromial impingement in college baseball pitchers. The research hypotheses are that there will be a correlation 1) between the KJOC score and the TIC by Park and 2) between the KJOC and the Hawkins-Kennedy impingement, the painful arc, and the infraspinatus muscle strength tests individually.

Design

Cross-sectional pilot study.

Methods

Twenty-one collegiate baseball pitchers completed the KJOC and then were tested using the Park test-item cluster.

Data Analysis

Kruskal-Wallis was used to test the relationship of individual demographics with KJOC scores. Spearman rho correlation was used to determine if the number of positive clinical tests in the Park TIC or with the individual tests within the TIC correlated with scores on the KJOC.

Results

No significant relationships between KJOC scores and demographics were found. A significant moderate-to-good relationship was found between the painful arc test and the KJOC (r = -.601, p = 0.00) and a significant fair correlation was found between the number of positive tests within the Park TIC and KJOC (r = -.426, p = 0.05). No significant relationships were found between the Hawkins-Kennedy and KJOC (r = -.348, p = 0.12) or between the infraspinatus strength test and KJOC (r = -.040, p = 0.86).

Conclusion

The correlations between the painful arc test and the number of positive impingement tests with the composite score on the KJOC suggests a relationship between these two outcome measures, shoulder irritability, and decreased function in collegiate baseball pitchers. Of the three tests included in the Park TIC, the painful arc test was the only one with an independent significant correlation to the KJOC. The combination of impairment-specific cluster testing and an activity-focused self-assessment tool could be utilized to identify potential pathology and alert the medical professional that assessment and intervention are necessary.

Level of Evidence

Level 2 (Diagnosis).

Relationship between the lateral acromion angle and postoperative persistent pain of distal clavicle fracture treated with clavicle hook plate

Background

The clavicular hook plate is an accepted surgical procedure for distal clavicle fractures. The relationship of the characteristics of the hook plate, acromioclavicular joint and acromion morphology, and clinical outcome has remained poorly understood. We reviewed the clinical records of patients who had distal clavicle fractures with different lateral acromion angles treated using a clavicle hook plate and evaluated their clinical outcomes with respect to shoulder pain and acromial morphology.

Methods

We retrospectively reviewed 102 patients with distal clavicle fractures treated with hook plates at our institution from 2010 to 2017. They were divided into four groups according to lateral acromion angle on shoulder AP view X-rays. The angle was defined as the incline angle between the superior surface of distal clavicle and the inferior facet of acromion on coronal plane. We reviewed their clinical features, including Neer’s impingement sign, MRI findings, and outcomes using Japanese Orthopaedic Association Scores. The mean follow-up was 25.5 months (range, 24 to 28 months).

Results

All patients in group D (large lateral acromion angle (α) > 40°, acromion coronal angle (β) < 60°) complained of postoperative symptoms. Compared to those with common lateral acromion angle, the incidence of postoperative impingement in group D was undoubtedly much higher (100%). Japanese Orthopaedic Association (JOA) scores in group D were worse at 3 months post-surgery, 3 months post plate removal, and at the last follow-up despite a slightly earlier removal in this group.

Conclusion

Lateral acromion angle appears to be an important factor in the development of postoperative pain and worse outcomes (JOA scores) in patients treated with the hook plate. The incidence of subacromial impingement and rotator cuff lesion (RCL) increased with the α angle. Early limited mobility and removal of the implant may improve the prognosis and resolve the postoperative shoulder pain.

Study design

Retrospective review, level of evidence IV.

Ultrasound-Guided Versus Anatomic Landmark-Guided Steroid Injection of the Subacromial Bursa in the Management of Subacromial Impingement: A Systematic Review of Randomised Control Studies

This study is a systematic review of prospective randomised control studies comparing ultrasound-guided steroid injection of the subacromial space with anatomic landmark-guided injection in the treatment of subacromial impingement to determine if there is any difference in pain relief and functional outcome. Mesh terms and free-text words search of electronic databases, reference list of identified studies and grey literature was performed using the PICO format. All identified papers were sifted sequentially by title, abstract and review of full text articles. Four papers qualified and were included in the review and analysis. The total number of patients in the studies was 234 patients with 117 patients randomised to each of landmark-guided and ultrasound-guided injection groups. There was no statistically significant difference in VAS pain scores (P = 0.67), SDQ scores (P = 0.43), SPADI disability score (P = 0.17) and functional outcomes scores (P = 0.09) at 4 to 6 weeks when USS-guided subacromial steroid injection was compared with landmark-guided injection. SPADI pain scores (P = 0.02) demonstrates significant reduction in favour of landmark-guided injection. There was low to moderate risk of bias. In conclusion, ultrasound-guided subacromial steroid injection does not offer any statistically significant clinical improvement over landmark-guided injection in adults with subacromial impingement.

Guided versus freehand acromioplasty during rotator cuff repair. A randomized prospective study

INTRODUCTION

There is no consensus on how to perform acromioplasty, particularly regarding the level and extent of bone resection, which depend on scapular and humeral morphologies.

HYPOTHESIS

We aimed to determine whether computer-assisted acromioplasty planning helps surgeons remove impinging bone, reduce unnecessary resections, and improve short-term outcomes of rotator cuff tears (RCR).

PATIENTS AND METHODS

We randomized 64 patients undergoing RCR of full-thickness supraspinatus tears into two groups: 'guided acromioplasty' (GA) and 'freehand acromioplasty' (FA). The pre- and post-operative scapula models were reconstructed using computed-tomography scans to quantify impinging bone removal, unnecessary bone resections, and identify zones of acromial bone removal. All patients were evaluated preoperatively and at 6 months to assess their range of motion (ROM), functional scores and tendon integrity using ultrasound.

RESULTS

The two groups did not differ in demographics, clinical or morphologic characteristics. Compared to FA, GA tended to lower impinging bone removal (55±26% vs. 43±27%, p=0.087) and to increase unnecessary resection of the total bone removed (49±22% vs. 57±27%, p=0.248). GA resulted in significant anterior under-resection, while FA resulted in significant medial over-resection. Clinical outcomes and ROM improved significantly for all patients, except for internal rotation in the GA group. There were no other significant differences between the two groups, neither in terms of post-operative scores nor in terms of clinical net improvements, nor tendon repair integrity.

CONCLUSIONS

This computer-assisted planning for acromioplasty during RCR proved no benefits in terms of bone removal, tendon healing, or clinical outcomes. Nonetheless such planning tools could help less experienced surgeons improve the efficacy of acromioplasty.

LEVEL OF PROOF

I, Randomized controlled trial (Therapeutic study).

Outcomes of ketorolac versus depomedrol infiltrations for subacromial impingement syndrome: a randomized controlled trial

PURPOSE

Local subacromial infiltration with steroids is a common method of treatment of subacromial impingement syndrome. However, the use of steroids has concerns like tendon rupture, articular cartilage changes and infections. Local NSAIDs infiltration has recently been tried in literature. This study compares the effect of subacromial injections of ketorolac with steroids.

METHODS

A randomized controlled study was planned with 35 patients in each group. Patients in group-1 were infiltrated with subacromial ketorolac (60 mg with 2% lignocaine) and in group-2 with a steroid (methylprednisolone-40 mg with 2% lignocaine). A similar rehabilitation protocol was followed, and clinical outcomes were analyzed using visual analog scale (VAS) for pain and shoulder pain and disability score (SPADI) and range of motion at one-month and three-months follow-up.

RESULTS

Total data of 67 patients were analyzed, as three patients were lost to follow-up. In group 1, mean VAS improved from 7.9 [Formula: see text] 0.95 to 3.19 [Formula: see text] 0.81 (p < 0.001) and SPADI improved from 61.41 [Formula: see text] 11.86 to 28.91 [Formula: see text] 9.06 (p < 0.001) at three months, respectively. In group 2, mean VAS improved from 8.05 [Formula: see text] 0.94 to 2.9 [Formula: see text] 0.64 (p < 0.001) and SPADI improved from 63.45 [Formula: see text] 9.64 to 25.32 [Formula: see text] 6.87 (p < 0.001) at three months, respectively. However, there were no differences in functional outcomes between the groups (p = 0.21 for VAS, p = 0.16 for SPADI).

CONCLUSION

Subacromial ketorolac infiltration has an equivalent outcome as that of steroid infiltration. Ketorolac could be considered as a reasonable alternative to steroids in cases where it is contraindicated.

[Indications and techniques of arthroscopic anterior and lateral acromioplasty]

OBJECTIVE

Arthroscopic anterior acromioplasty (AAAP) for treatment of symptomatic subacromial spur. Arthroscopic lateral acromioplasty (ALAP) to reduce a pathological critical shoulder angle (CSA) and prevent rotator cuff re-tear after reconstruction.

INDICATIONS

AAAP is indicated for acromial impingement due to an anterolateral acromial spur with or without bursa-sided rotator cuff lesion. ALAP is indicated concomitant to arthroscopic rotator cuff repair if the CSA is pathologically increased.

RELATIVE CONTRAINDICATIONS

Irreparable rotator cuff tear with acetabularization of the acromion due to anterosuperior escape of the humeral head or symptomatic os acromiale can contraindicate for AAAP. Dehiscence of the origin of the deltoid muscle or symptomatic os acromiale can contraindicate for ALAP.

SURGICAL TECHNIQUE

To preform AAAP, arthroscopic subacromial decompression is followed by anterolateral resection of an acromion spur or ossification of the coracoacromial ligament. To perform ALAP, arthroscopic subacromial decompression and reconstruction of a rotator cuff-tear is followed by reduction of a pathologically increased CSA by resection of the lateral edge of the acromion.

POSTOPERATIVE MANAGEMENT

After isolated AAAP, physiotherapy can be performed without restriction. After AAAP or ALAP combined with rotator cuff repair, immobilization in a brace is recommended. The use of pain medication should be standardized and adapted to individual pain levels.

Subacromial impingement anatomy and its association with rotator cuff pathology in women: radiograph and MRI correlation, a retrospective evaluation

OBJECTIVE

To evaluate the relationships between acromial anatomy and developmental alterations with rotator cuff tears in female patients and compare these parameters on radiographs and corresponding MRIs along with inter-reader performance.

MATERIALS AND METHODS

Patient demographics, symptoms, and acromial characteristics on radiograph (acromial index, lateral acromion angle, subacromial space on AP and Y- views, acromial anterior and lateral downsloping) and MRI (shape, slope, spur, osteoarthrosis, os acromiale) were recorded. Radiographic and MRI findings were compared and correlated with rotator cuff pathology on MRI. Inter-reader analysis was performed.

RESULTS

A total of 140 MRIs from 137 female patients were included. No significant correlation (p > 0.05) existed between acromial parameters and rotator cuff tears, except for a smaller subacromial space on the Y view and spurs correlated with subscapularis tendon tear (p = 0.02, p = 0.04). The presence of lateral downsloping on MRI correlated with a smaller lateral acromion angle (p = 0.0002) and the presence of lateral downsloping on radiography (p = 0.0015). Inter-reader agreements were good to excellent (ICC: 0.65-0.89).

CONCLUSION

Subacromial impingement anatomy characteristics have no significant associations with supraspinatus or infraspinatus tears in symptomatic women. Among different measures, supine MRI can be reliably used to identify lateral downsloping of the acromion.

Sexual Activities as Risk Factors of Rotator Cuff Lesions: A Prospective Cohort Study

The aim of this study was to analyze the occurrence of rotator cuff impingement due to reduction of subacromial space height during complex shoulder motion to determine safety of sexual activities. The hypothesis was that such activities could be deleterious if not performed with precaution. To use a patient-specific 3D measurement technique coupling medical imaging and optical motion capture to evaluate the safety of various sexual positions according to subacromial compression. Descriptive laboratory study. A volunteer couple underwent Magnetic Resonance Imaging (MRI) and motion capture of their shoulders. Five common active and passive sexual positions were evaluated. Significant differences in subacromial space height were observed between the different performed actions. All active sexual positions requiring important pressure on the hands or elbows (e.g., scorpio) or weight lifting (e.g., superman) caused subacromial impingement. No subacromial impingement was however observed during passive sexual activities (e.g., basset hound). This study indicates that some sexual positions could potentially place the rotator cuff at risk. Such high-tech investigation shows promise in the areas of cause, intervention and education. The present findings may assist health professionals in providing them with preventive measures and is highly relevant for decision-making regarding health promoting initiatives.

Combined arthroscopic and open operative management of an intramuscular supraspinatus lipoma in the treatment of subacromial impingement syndrome: A case report

•

Subacromial impingement syndrome encompasses a spectrum of pathologies.

•

Further investigation is warranted beyond simple imaging when the pathology is not apparent.

•

Benign lipomas can be diagnosed as the cause of subacromial impingement syndrome using MRI.

•

Combined arthroscopic and open approach allows for multifaceted management in one procedure.

Introduction

Subacromial impingement syndrome (SAIS) is one cause of shoulder pain and encompasses a spectrum of pathologies and is not an isolated entity.

Presentation of case

We present a rare case where a 40 year old male presented with a 3 year history of right shoulder tip pain with limited abduction to 30°, external rotation to 45°, preserved internal rotation and forward flexion and a painful arc with positive Neers and Hawkins-Kennedy signs for impingement consistent with SAIS. The presentation occurred in the setting of a supraspinatus intramuscular lipoma demonstrated on shoulder MRI. This was managed operatively with a combined arthroscopic and open approach to allow performance of a bursectomy, debridement of mild acromioclavicular joint degeneration and lipoma excision. The patient was discharged on the first post-operative day. He was managed in a sling for 4 weeks with a graduated exercise program over the first 12 weeks with full shoulder strength and function maintained at 12 months.

Discussion

Lipoma as a cause of SAIS is rare but an important diagnosis that needs to be considered in the preoperative evaluation of SAIS to guide appropriately targeted surgical management.

Conclusion

This case reinforces the diversity of pathologies in SAIS and the breadth of differential diagnoses that need to be considered when evaluating and determining the appropriate surgical approach to maximise chance of symptom resolution in SAIS.

Progressive conscious control of scapular orientation with video feedback has improvement in muscle balance ratio in patients with scapular dyskinesis: a randomized controlled trial

BACKGROUND

Video feedback (VF) can guide patients to consciously control scapular orientation without inappropriate substitution. This study investigated whether progressive conscious control with VF improves scapular muscle activation and movements during arm elevation in patients with subacromial impingement and scapular dyskinesis.

METHODS

The study recruited 38 amateur overhead athletes with subacromial impingement and scapular medial border prominence who were randomly assigned to the VF or control group. The participants in both groups controlled the scapular position and progressively practiced from 0° to 45° and from 0° to 90° of arm elevation. Participants in the VF group also controlled the scapular position with a video presentation of the scapula on a screen. We investigated the scapular kinematics, muscle activation, and balance ratio for outcome collection in the preintervention and postintervention conditions with and without VF conditions.

RESULTS

Decreased upper trapezius (UT) activation (3%-13%, P < .0083), increased lower trapezius (LT) activation (3%-17%, P < .0083), restored UT/LT ratios (0.67-3.13, P < .0083), and decreased scapular internal rotation (1.8°-6.1°, P < .003) relative to the preintervention condition were demonstrated in the 2 postintervention conditions in both groups. The VF group also demonstrated decreased UT/serratus anterior ratios (0.21-0.30, P < .0083) in 2 postintervention conditions relative to the preintervention condition.

CONCLUSIONS

The progressive control of scapular orientation with or without VF can be used to reduce the UT/LT ratio and improve scapular internal rotation during arm elevation. Control training with VF can further decrease the UT/serratus anterior ratio.

ArthroPlanner: a surgical planning solution for acromioplasty

PURPOSE

We present a computer-assisted planning solution "ArthroPlanner" for acromioplasty based on 3D anatomical models, computed tomography and joint kinematic simulations.

METHODS

In addition to a standard static clinical evaluation (anamnesis, radiological examination), the software provides a dynamic assessment of the shoulder joint by computing in real time the joint kinematics from a database of activities of daily living. During motion, the precise bone resection (location and amount) is computed based on detected subacromial impingements, providing surgeons with precise information about the surgical procedure. Moreover, to improve the subjective reading of medical images, the software provides 3D measurement tools based on anatomical models assisting in the analysis of shoulder morphological features.

RESULTS

We performed an in vivo assessment of the software in a prospective randomized clinical study conducted with 27 patients beneficiating from the planning solution and a control group of 31 patients without planning. Postoperatively, patient's pain decreased, and the shoulder range of motion and the functional outcomes improved significantly and the rotator cuff healing rate was good for both groups without intergroup differences. The amount of bone resected at surgery was comparable between the groups. The percentage of remaining impingement after surgery was in average reduced to 51% without groups difference.

CONCLUSIONS

ArthroPlanner software includes all required materials (images data, 3D models, motion, morphological measurements, etc.) to improve orthopedists' performance in the surgical planning of acromioplasty. The solution offers a perfect analysis of the patient's anatomy and the ability to precisely analyze a dynamic mechanism to fully apprehend the patient's condition and to fulfill his/her expectations. The study however failed to detect any statistically significant difference in clinical outcomes and bone resection between the groups. Short-term clinical and radiological results were excellent in both groups.

More histologic and ultrastructural degenerative signs in the subscapularis tendon and the joint capsule in male patients with shoulder impingement

PURPOSE

The purpose of the present study was to analyze biopsy samples from the subscapularis tendon and from the joint capsule from male patients with shoulder impingement syndrome (SAIS) and compare them with samples from male patients with post-traumatic recurrent shoulder instability. The hypothesis of the study was that patients with SAIS would have more histologic and ultrastructural degenerative changes in their subscapularis tendon and joint capsule than patients with post-traumatic recurrent shoulder instability.

METHODS

Male patients scheduled for surgery, with either subacromial decompression or Bankart reconstruction, were included. Four biopsies from each patient were obtained from the capsule and four from the subscapularis tendon during arthroscopic surgery. The histologic characteristics and the presence of glycosaminoglycans were assessed using the light microscope, and the ultrastructure was assessed using a transmission electron microscope.

RESULTS

Eight patients, median age 53 (45-74) years (p < 0.0001), were included in the impingement group, and 12 patients, median age 27 (22-48) years, were included in the instability group. The histologic assessment revealed significantly higher cellularity and total degeneration score in the capsule (p = 0.016 and p = 0.014 respectively) in patients with subacromial impingement compared with the instability patients. The corresponding finding was not made for the subscapularis tendon. The ultrastructural evaluation revealed that the instability patients had more fibrils with a large diameter (indicating less degeneration) in both the subscapularis tendon and the capsule compared with the impingement patients (p < 0.0001).

CONCLUSION

Male patients with subacromial impingement have more histologic and ultrastructural degenerative changes in their shoulder compared with patients with post-traumatic recurrent shoulder instability.

CLINICAL RELEVANCE

It appears that in patients with subacromial impingement, the whole shoulder joint is affected and not only the subacromial space. It is the opinion of the authors that intra-articular therapeutic injections could be tried more often in these patients.

LEVEL OF EVIDENCE

III.

Does taping in addition to physiotherapy improve the outcomes in subacromial impingement syndrome? A systematic review

BACKGROUND

Taping is used with or without other interventions for many purposes, especially to manage pain and improve functional activity in patients with shoulder pain.

OBJECTIVES

The aim of this review was to determine whether any taping technique in addition to physiotherapy care is more effective than physiotherapy care alone in patients with shoulder impingement syndrome.

METHODS

A systematic search of Cochrane Database of Systematic Review, MEDLINE (EBSCO), Physiotherapy Evidence Database (PEDro), CINAHL (EBSCO), PUBMED, AMED, EMBASE (OVID), The Kinesio Kinesio® Taping Method, Kinesio® Tex Tape UK and International websites ( www.kinesiotaping.co.uk ; www.kinesiotaping.com ) was conducted to June 2015. The outcome measures were pain, disability, range of motion and muscle strength. As data were not suitable for meta-analysis, narrative synthesis were applied.

RESULTS

Three randomized controlled trials and one controlled trial (135 patients) were included. The results were conflicting and weak on the effectiveness of taping as an adjunct therapy for improvement of pain, disability, range of motion and muscle strength.

CONCLUSION

Clinical taping in addition to physiotherapy interventions (e.g. exercise, electrotherapy, and manual therapy) might be an optional modality for managing patients with shoulder impingement syndrome, especially for the initial stage of the treatment; however, we need further robust, placebo controlled and consistent studies to prove whether it is more effective than physiotherapy interventions without taping.

Physical examination tests of the shoulder: a systematic review and meta-analysis of diagnostic test performance

BACKGROUND

Physical examination tests of the shoulder (PETS) are clinical examination maneuvers designed to aid the assessment of shoulder complaints. Despite more than 180 PETS described in the literature, evidence of their validity and usefulness in diagnosing the shoulder is questioned.

METHODS

This meta-analysis aims to use diagnostic odds ratio (DOR) to evaluate how much PETS shift overall probability and to rank the test performance of single PETS in order to aid the clinician's choice of which tests to use. This study adheres to the principles outlined in the Cochrane guidelines and the PRISMA statement. A fixed effect model was used to assess the overall diagnostic validity of PETS by pooling DOR for different PETS with similar biomechanical rationale when possible. Single PETS were assessed and ranked by DOR. Clinical performance was assessed by sensitivity, specificity, accuracy and likelihood ratio.

RESULTS

Six thousand nine-hundred abstracts and 202 full-text articles were assessed for eligibility; 20 articles were eligible and data from 11 articles could be included in the meta-analysis. All PETS for SLAP (superior labral anterior posterior) lesions pooled gave a DOR of 1.38 [1.13, 1.69]. The Supraspinatus test for any full thickness rotator cuff tear obtained the highest DOR of 9.24 (sensitivity was 0.74, specificity 0.77). Compression-Rotation test obtained the highest DOR (6.36) among single PETS for SLAP lesions (sensitivity 0.43, specificity 0.89) and Hawkins test obtained the highest DOR (2.86) for impingement syndrome (sensitivity 0.58, specificity 0.67). No single PETS showed superior clinical test performance.

CONCLUSIONS

The clinical performance of single PETS is limited. However, when the different PETS for SLAP lesions were pooled, we found a statistical significant change in post-test probability indicating an overall statistical validity. We suggest that clinicians choose their PETS among those with the highest pooled DOR and to assess validity to their own specific clinical settings, review the inclusion criteria of the included primary studies. We further propose that future studies on the validity of PETS use randomized research designs rather than the accuracy design relying less on well-established gold standard reference tests and efficient treatment options.

Empty can exercise provokes more pain and has undesirable biomechanics compared with the full can exercise

BACKGROUND

The purpose of this investigation was to characterize the scapular position and scapular muscle activation during the empty can (EC) and full can (FC) exercises. The EC exercise has been shown to produce scapular kinematics associated with the mechanism leading to subacromial impingement syndrome (SAIS) but has not been investigated in patients with (SAIS). This investigation will help improve the treatment of patients with SAIS.

METHODS

Participants with SAIS (n = 28) performed 5 consecutive repetitions of FC and EC exercises. Scapular and clavicular 3-dimensional positions and scapular muscle activity were measured during each exercise. Pain was measured with the numeric pain rating 11-point scale.

RESULTS

Participants reported greater pain during the EC exercise vs the FC exercise (difference, 1; P = .003). During the EC exercise, participants were in greater scapular upward rotation (difference, 3°; P < .001), internal rotation (mean difference, 2°; P = .017), and clavicular elevation (difference, 3°, P < .001) and in less scapular posterior tilt (difference, 2°; P < .001). There was greater activity of upper trapezius (difference, 4%, P = .002), middle trapezius (difference, 3%; P < .001), and serratus anterior (difference, 0.5%; P = .035) during ascent, and during the descent of greater upper trapezius (difference, 2%, P = .005), and middle trapezius (difference, 1%; P = .003), but less activity of the lower trapezius (difference, 1%; P = .039).

CONCLUSIONS

The EC exercise was associated with more pain and scapular positions that have been reported to decrease the subacromial space. Scapular muscle activity was generally higher with the EC, which may be an attempt to control the impingement-related scapular motion. The FC exercise of elevation is preferred over the EC exercise.

Medium-term natural history of subacromial impingement syndrome

BACKGROUND

We evaluated the factors that affect the natural course of subacromial impingement syndrome in patients without rotator cuff tears.

METHODS

In total, 63 patients were included. During the first evaluation, we recorded each patient's age, gender, profession, body mass index (BMI), hand dominance, alcohol and tobacco consumption, comorbidities, causative event of pain, presence of a functional limitation, duration of symptoms, shoulder scores (American Shoulder and Elbow Surgeons [ASES], Constant-Murley, and visual analog scale), history of subacromial steroid injections, and magnetic resonance imaging (MRI) classification. A subacromial lidocaine injection test was performed to confirm the diagnosis, and patients were initially treated conservatively. Of the 63 patients, 7 underwent a subsequent surgical procedure. We recalled the patients and questioned them about recurrences. According to their answers, the patients were grouped as follows: group 1, no recurrence; group 2, relapsing course; and group 3, chronic course. We compared the groups regarding the factors proposed to affect the course of the disease.

RESULTS

The mean follow-up time was 8.45 ± 0.9 years. There were no significant differences regarding gender, profession, hand dominance, alcohol consumption, smoking, comorbidities, causative event of pain, visual analog scale score, or history of subacromial steroid injections between groups. The patients in group 1 were significantly younger than those in group 2 (P = .038). The mean BMI value of the group 1 patients was significantly lower than that of the group 3 patients (P = .034). Patients with a functional limitation besides pain tended to have a relapsing course. The Constant-Murley and ASES scores were significantly higher for patients in group 1 than for patients in group 2 (P = .024 and P = .041, respectively). The duration of symptoms was significantly shorter (<3 months) in group 1 (P = .001). Most of the patients in group 1 had reversible changes on MRI (P = .038).

CONCLUSION

In our study, younger age, lower BMI, more functional capacity, a shorter symptomatic period, reversible changes on MRI, and higher Constant and ASES scores at the first evaluation were good prognostic factors.

Distribution of bone and tissue morphological properties related to subacromial space geometry in a young, healthy male population

PURPOSE

Particular bone and tissue morphological features of the scapula and humerus often exist disproportionately in persons with subacromial impingement syndrome (SAIS) and/or rotator cuff pathology. However, the origins of morphological variation, genetic or mechanistic, remain unclear. This research evaluated the distribution of and correlation between several bone and tissue characteristics associated with these pathologies amongst a baseline cohort population consisting of young, healthy, males. As well, the predisposition to SAIS was estimated by calculating the ratio (occupation ratio) of subacromial tissue thickness to minimum subacromial space width (SAS).

METHODS

Anterior-posterior and trans-scapular radiographs and musculoskeletal ultrasound were used to measure morphological characteristics related to the subacromial space. Each bone morphological characteristic was classified as healthy or unhealthy based on previous definitions. Supraspinatus tendon and subacromial bursa thicknesses were used to calculate the occupation ratio from both radiographic and ultrasonic measures of the SAS.

RESULTS

Each characteristic demonstrated considerable variability, with some participants having 'unhealthy' variants for each bone characteristic examined. The percentage of the population with bone characteristics classified as "unhealthy" ranged from 15 to 55 % across characteristics evaluated. The strongest correlation existed between the acromion index and the minimum subacromial space width (-0.59) suggesting that a larger lateral extension of the acromion may predispose an individual to SAIS. The average occupation ratio was 65.3 % with a 1-99 % confidence interval ranging from 21.6 to 108.9 %.

CONCLUSIONS

The distributions of both morphological characteristics and occupation ratios indicate that individuals within this healthy, baseline population have a highly differential predisposition for subacromial tissue compression solely based on inherent morphological variation. This suggests that while mechanistic and/or age-related degenerative changes may contribute to SAIS and eventual rotator cuff pathology, intrinsic predisposing geometry should not be discounted.

Do subacromial ultrasonography findings predict efficacy of intra-bursal injection? Prospective study in 39 patients

BACKGROUND

Ultrasonography has become an investigation of choice in the management of shoulder pain. The objective of this study was to determine whether the efficacy of subacromial-subdeltoid bursa injection correlated with the ultrasound findings.

MATERIAL AND METHODS

We prospectively recruited patients who were seen between November 2012 and November 2013 for subacromial pain and whose rotator cuff was either intact or showed a full-thickness tear less than 1cm in length. A standardised physical examination of the shoulder was followed immediately by static and dynamic ultrasonography, intra-bursal injection of lidocaine, and a repetition of the same physical examination. Recorded ultrasonography features were the appearance of the bursa, shape of the coraco-acromial ligament, and bursal deformation induced by passage under the coraco-acromial ligament during dynamic imaging. A response to the injection was defined as greater than 75% improvements in at least three of the physical examination parameters.

RESULTS

We included 39 patients with a mean age of 56.7 years. Ultrasonography showed abnormalities of the bursa in 30 patients, including 1 with an intra-bursal effusion, 10 with thickening, and 19 with both. Deformation of the bursa under the coraco-acromial ligament was noted in 26 patients. The proportions of patients with bursal effusion and with bursal thickening were similar in the 20 responders and 19 non-responders. Neither were any significant differences found for coraco-acromial ligament shape or bursal deformation under the ligament.

CONCLUSIONS

No correlation was found between ultrasonography findings and the efficacy of a local anaesthetic injection into the subacromial bursa. These findings suggest that ultrasound abnormalities may constitute mere physiological changes, in keeping with earlier studies in asymptomatic individuals. Thus, subacromial impingement may be currently overdiagnosed.

Coracoacromial ligament section under ultrasonographic control: a cadaveric study on 20 cases

INTRODUCTION

The coracoacromial ligament is a complex anatomical structure involved in the development of subacromial impingement; treatment is founded on sectioning the ligament, with or without associated arthroscopic acromioplasty and debridement.

HYPOTHESIS

Complete coracoacromial ligament section can be performed under ultrasound, without lesion to surrounding structures.

MATERIALS AND METHODS

The coracoacromial ligament was sectioned on the coracoid side, under ultrasound navigation, in 10 cadavers donated to science: i.e. 20 shoulders. After ultrasound location of the shoulder structures, sectioning was performed with a skin incision at the level of the deltopectoral sulcus. Secondary surgical control checked conservation of the acromial branch of the thoracoacromial artery, and the quality of the procedure.

RESULTS

Mean surgery duration was 18.5 minutes (±5 min). Seventeen sections were complete (85%). Artery location was hampered by the impossibility of using Doppler on these cadavers, yet even so there were only 2 vascular lesions. There were no accidental rotator cuff or cartilaginous lesions.

CONCLUSION

This relatively non-invasive technique is quick and less heavy than open surgery, opening up new treatment perspectives. It could be indicated in coracoid and subacromial impingement before opting for surgery, or as a complement to surgery. It does, however, involve a learning curve and requires solid ultrasound skills.

Scapular orientation following repetitive prone rowing: implications for potential subacromial impingement mechanisms

While fatigue of the rotator cuff demonstrably causes superior humeral head migration and concomitant risk of impingement, the relationship between specific muscular fatigue, scapular dyskinesis and impingement risk is less clear. The purpose of this study was to examine changes in scapular orientation following a simulated prone rowing fatiguing protocol that targeted the scapula stabilizing muscles while attempting to alleviate rotator cuff muscular demands. Scapular orientation and muscle activity were collected from participants before and immediately after the fatiguing task. This task fatigued both the stabilizing (upper and middle trapezius, and latissimus dorsi) and rotator cuff (supraspinatus, and infraspinatus) muscles. The upper extremity muscle fatigue pattern caused by the protocol did not elicit any significantly changes in three-dimensional scapular position with all post-fatigue changes being ≤ 1° (p = 0.17-0.58). These results indicated that scapular reorientation is likely not the dominant mechanism of fatigue-induced subacromial impingement development. However, the substantial variability present in the kinematics prevents complete exclusion of scapular dyskinesis as a secondary causal mechanism of impingement.